Vomiting may occur in attacks sug gesting those of tabes, but usually with out pain.
Case observed in which the disease ran an unusually-rapid course, as the patient lived just three months after the symp toms first made themselves apparent. The most important and obstinate symp tom was vomiting and distressing retch ing at even the sight of food. Sutcliff (Lancet, Mar. 12, '93).
Signs of impaired local nutrition may be present in the form of swellings of the joints, as of the fingers, ulcerations of the cornea,—due partly, but not wholly, to exposure arising from the wide lid openings,—and various affections of the skin and its appendages,—as vitiligo, pigmentation, falling of the hair, inflam mation about the nails, scleroderma, sweating, erythema, urticaria, and leuco derma.
Pigmentary changes in the skin ob served in five patients. The color is a more or less dark brown; the parts affected are the face, neck, sides of chest, abdomen, lumbar regions, axillx, and flexures of arms and thighs. II. W. G. Mackenzie (Lancet, Sept. 13, '90).
Case observed in which complete alo pecia was associated with exophthalmic goitre. Berliner (Monats. f. prak. der Mcd., vol. xxiii, No. 2, '96).
The fingers may become tapering and very movable in their articulations. It is possible that changes of this character, and others met with in Graves's disease, indicate changes in morphological tend encies of growth such as occur in myxce dema and after castration.
The spleen and lymph-glands may be come enlarged to the point of lymph adenoma (Gowers). The thymus is often persistent.
The uterus and the breasts—one or both—may atrophy prematurely, or, on the other hand, the breasts may enlarge. Basedow reported a case of this sort in a man.
The bones may become soft and it is said (Revilliod) that symptoms like those of Graves's disease may occur in osteo malacia.
Myxcedematous changes occur as a sequel to the thyroid atrophy which may follow the Graves-disease degeneration of the thyroid gland. Whether myxce dema and Graves's disease may truly be said to coincide is an open question, though various cases have been reported which indicate that this is possible.
Confirmatory evidence should be care fully noted and critically studied. The sorts of myxcedematons changes most likely to occur are non-pitting oedema, supraclavicular swellings, scleroderma, falling of the hair, mental dullness, atrophy of the breasts, disease of the bones and joints, dryness of the skin.
Diagnosis.—There is no difficulty in the diagnosis of a typical case of Graves's disease. On the other hand, in the early stages of very mild cases one may be able to do no more than suspect the presence of the trouble; yet this suspicion may be of great practical importance. There is, perhaps, no single symptom which may not be absent or so inconspicuous as not to challenge attention. Even the rapid pulse may, perhaps, be lacking. This is extremely rare, but pulse-rates of about ninety are not very uncommon. Persist ent tachycardia of any grade, persistent nervousness, agitation, and tremor, not associated with typical signs of neuras thenia or hysteria, or out of proportion to those signs, persistent—even if slight —suffusion of the face, and causeless diarrlicea should always awaken suspi cion, and if the patient has had an indo lent goitre for some years or has been recently exposed to severe emotional ex citement or any of the other exciting causes of Graves's disease, there will be all the more reason for thinking that the suspicion is well grounded. High tem perature, sweating, and loss of flesh, would all be confirmatory indications, but the presence of well-marked signs of hysteria or neurasthenia might, in the absence of an enlargement of the thy roid, offer another and sufficient explana tion. The diagnosis of what might be called the stage of predisposition — in which, of course, no positive symptom would be manifest, or only occasionally manifest—is perhaps impossible at the present day. Nevertheless, by the aid of careful observation some degree of success may at some future time be at tempted.